MEDICAL COLLEGE ADMISSION TEST+ (MCAT+) PROGRAM PROGRAM DATES: JUNE 13, 2016 – JULY 22, 2016 APPLICATION DEADLINE: 5:00 PM, FRIDAY, April 22, 2016 The Medical College Admission Test + (MCAT+) Program is designed to prepare students to take the MCAT by providing test preparatory for its participants so they can become competitive applicants to medical school. This program will challenge student achievement by balancing a rigorous curriculum with academic, social, and developmental support. MCAT+ students are expected to approach the experience with a commitment to scholarship and exploration. The MCAT+ Program will be located in Albuquerque, NM at the UNM Health Sciences Center campus. Interested applicants must be New Mexico residents, as defined by the UNM School of Medicine, http://som.unm.edu/education/md/apply/residency.html. Preferably, underrepresented in medicine and come from economically and/or educationally disadvantaged backgrounds. Applicants should demonstrate a commitment to increasing health equity. Applicants accepted in to our HEALTH NM pipeline programs must have a Social Security Number (SSN) or Individual Tax Identification Number (ITIN). Questions regarding citizenship, residency and/or application details can be directed to [email protected] or by calling 505-272-2728 or toll free 1-866-494-0064. Eligibility Requirements • Minimum GPA of 3.0 on a 4.0 scale • NM resident currently enrolled in college as a junior, senior, or graduate • Program Prerequisites & Co-requisites: o General Biology I & II (1 academic year, 2 semesters) o General Chemistry I & II (1 academic year, 2 semesters) o Organic Chemistry I & II (1 academic year, 2 semesters) o Physics I & II (1 academic year, 2 semesters) Participation Dates The program will begin on Monday, June 13, 2016 and end on Friday, July 22, 2016. Student participation is expected throughout the duration of the program. Participants will be required to be on campus from 8:00 am to 4:00pm, Monday through Friday, throughout the duration of the program. Schedule is subject to change. If accepted into the program, the Office for Diversity will send all participants an acceptance packet that must be completely filled out and returned to our office no later than Friday, May 20, 2016. Failure to include any of the supporting documents, not following directions completely, or leaving blank sections on this application form will result in an automatic disqualification. Additionally, failure to meet the April 22, 2016 deadline will result in automatic disqualification. To apply, please complete the attached application. ALL COMPLETED APPLICATIONS MUST BE SUBMITTED IN PERSON BY 5:00 PM OR POSTMARKED ON APRIL 22, 2016. FAXED APPLICATIONS WILL NOT BE ACCEPTED. SUBMIT COMPLETE APPLICATION BY April 22, 2016: Application Information at: http://hsc.unm.edu/programs/diversity/index.shtml Mail to: UNM HSC Office for Diversity MSCO9 5235 1 University of New Mexico Albuquerque, NM 87131-0001

Deliver in person to: UNM Health Science Center, UNM North Campus Office for Diversity Health Sciences and Services Building, Suite 102 Building #266, Campus Map

2016 MCAT+ Application Revised 1/21/16

MCAT+ PROGRAM PROGRAM DATES: JUNE 13, 2016 – JULY 22, 2016 APPLICATION CHECKLIST

APPLICANT NAME: Complete application packets must include: ¨ Complete Student Application ¨ College Transcript(s): An unofficial transcript from all the schools that you have attended ¨ Resume ¨ MCAT test score report(s). (If taken, it is required to report previous scores. It is not a requirement to be registered or have previously taken the MCAT.) ¨ Personal Statement: (The personal statement must be typed, double-spaced, 12-point font, Times New Roman, 1” margins, and no more than 2 pages.) Please state your purpose in applying to this program. In this personal statement we are seeking to capture not only a snapshot of where you are currently as a student but also where you have been and where you see yourself in the future as a health professional. Relevant factors include but are not limited to: • Achievements you have accomplished in spite of educational, social, and economic challenges. • What in your personal, work, or academic background has motivated your interest in a health career? • What are your educational goals and how will they impact you, your family, and your community? • What kind of educational experiences and skillset do you expect to gain this summer that will best assist you in reaching your career goals and dreams? ¨ Two Completed Recommendation Forms One form should be completed by someone who can evaluate your character and academic performance, such as a professor, teacher, counselor, principal, mentor, employer, or volunteer supervisor. The second form can be from someone of your choosing. Forms must be in a sealed envelope with the writer’s signature across the seal on the back of the envelope. Note: Only two recommendation letters will be reviewed. Applications not completed in full will not be considered. Do not leave any fields blank. Important Dates: Application Deadline: Notification of Acceptance to MCAT+ Program: Applicant required to respond to acceptance notification: Orientation Date: Program Dates: Graduation at UNM:

April 22, 2016 May 6, 2016 May 20, 2016 Week of June 6 – 10, 2016 June 13 – July 22, 2016 July 22, 2016

Office Use Only Date Submitted: Staff Initials:

2016 MCAT+ Application Revised 1/21/16

MEDICAL COLLEGE ADMISSION TEST+ (MCAT+) PROGRAM ALBUQUERQUE, NEW MEXICO STUDENT APPLICATION PERSONAL INFORMATION Please make sure that the information given in this section is accurate and matches with any federal or state issued document (ex. Social security card, ITIN card). 1.

Name:

2.

Address:

Last

First

Middle

Street Address or P.O. Box Number City or Town

County

State

3.

Phone:

4.

Gender:

□ Female □ Male

5.

U.S. Citizen:

□ Yes

6.

New Mexico Resident:

7.

Date of Birth:

8.

Do you consider yourself to be Hispanic/Latino(a)? □ Yes □ No In describing yourself, please select one or more of the following racial categories: □ American Indian or Alaskan Native (Specify affiliation):

Zip

Email Address: □ No

If no, can you provide a SSN or ITIN:

□ Yes

□ No

□ Yes

□ No

If no, state of residency: 9. Place of Birth:

□ Asian □ Black or African American □ Native Hawaiian/Pacific Islander □ White □ Other (Please specify): 9.

What language(s) do you speak? What is the primary language spoken at home? What was your first language?

EDUCATIONAL BACKGROUND 10.

Please list schools you are attending and/or have attended beginning with high school: School Name

City and State

Dates of Attendance

Cumul. GPA

High School: College: College: 11.

Indicate your current year in college: □ Freshman

□ Sophomore

□ Junior

□ Senior

□ Graduate

Please indicate anticipated or actual college graduation date: 12.

Undergraduate Major/Minor:

13.

Overall GPA:

14.

Please list general prerequisite courses that you have taken (indicate course numbers): General Biology: Organic Chemistry:

Graduate Program:

General Chemistry: Mathematics:

General Physics: English:

15.

Have you taken the MCAT? □ Yes □ No If so, please list score(s) and date(s). (Please attach copy of MCAT score report.)

16.

If not, please list the date you intend to take it:

2016 MCAT+ Application Revised 1/21/16

FAMILY BACKGROUND Parent/Guardian 1 (Required): Applicant lives with this parent/guardian: □ Yes 17.

Name:

18.

Address:

Last

□ No

First

Middle

Street Address or P.O. Box Number City or Town

County

19.

Phone:

20.

Circle highest grade completed: 1

21.

Did your father/guardian attend college?

22.

Please check the highest level of degree obtained?

State

Email Address:

□ Associate Degree 23.

Occupation:

24.

Employer:

2

3

4

5

6

7

8

□ Yes

□ Bachelor’s Degree

9

10

11

Name:

26.

Address:

12

□ No

□ Master’s Degree

Parent/Guardian 2 (Required): Applicant lives with this parent/guardian: □ Yes 25.

Zip Code

Last

□ Doctoral Degree

□ Other

□ No

First

Middle

Street Address or P.O. Box Number City or Town

County

27.

Phone:

28.

Circle highest grade completed: 1

29.

Did your mother/guardian attend college?

30.

Please check the highest level of degree obtained? Occupation:

32.

Employer:

Zip Code

Email Address:

□ Associate Degree 31.

State

2

3

4

5

6

7

8

□ Yes

□ Bachelor’s Degree

9

10

11

12

□ No

□ Master’s Degree

□ Doctoral Degree

□ Other

FINANCIAL BACKGROUND 33.

I am currently financially supported by (check all that apply): □ Self

□ Father

□ Mother

□ Other (state relationship to you):

34.

Total Annual Household Income:

35.

How many people live in your household (include yourself)?

36.

Number of children or dependents in your household (include ages):

ADDITIONAL INFORMATION 37. Do you have any relatives in a health profession? 38.

□ Yes

□ No

Which specific fields?

Have you completed any other UNM HSC Office for Diversity programs (select all that apply)? □ Dream Makers/Dream Makers + □ STEAM-H Program

□ HCA □ USHEP □ Pre-College Science & Math Program

2016 MCAT+ Application Revised 1/21/16

39.

How did you find out about this program? □ Office for Diversity

□ Friend/Parent

□ Instructor/Advisor □ Flyer/brochure

□ Web Publications (websites, listserv) □ Other (specify):

40.

Please list your health career interest(s):

41.

Please list any health related certifications or training you have received and date of completion (i.e. CPR, First Aid):

42.

Please list extra-curricular, volunteer, and/or community experiences: (i.e. sports, school clubs, church activities, etc.)

43.

Do you have any other obligation during the program Participation Dates that may interfere with your ability participate in this program? □ Yes □ No

44.

If answered yes, please include information and dates for things such as (but not limited to), anticipated travel, employment, college orientation, etc.

45.

If applicable, please list any special needs or considerations you would like us to be aware of:

STATEMENT OF CERTIFICATION I certify that all information given is true to the best of my knowledge. I understand that failure to disclose accurate information is grounds for dismissal from or selection into the program Signature of Applicant

Date

2016 MCAT+ Application Revised 1/21/16



  RECOMMENDATION  FORM  –  PLEASE  RETURN  THIS  WITH  YOUR  APPLICATION    

  To the Applicant Please fill in your name on the line below and give this information to the individual you have selected provide a recommendation for you.

Applicant’s Name To the recommending individual The student named above is applying to the UNM Health Sciences Center, Office for Diversity’s Medical College Admission Test + (MCAT+) Program. This program’s purpose is to prepare students to take the MCAT by providing test preparatory for its participants so they can become competitive applicants to medical school. This program will challenge student achievement by balancing a rigorous curriculum with academic, social, and developmental support. This program seeks to identify students who demonstrate the following characteristics: • • • • •

Financial need; Academic performance or promise; Interest in pursuing a health related career; Strength of character, evidence of leadership potential, and emotional maturity and stability; The potential to contribute to one’s community later in life.

Please provide your contact information below, in the case that the Office for Diversity staff has any pending questions or concern. Recommender Name: Phone Number: Email: Relationship to Applicant: To help in the selection of participants into the Medical College Admission Test + Program, we ask that you please answer all of the following questions. Please limit your answers to the allotted space provided. ALL COMPLETED RECOMMENDATION FORMS MUST BE SUBMITTED IN A SEALED ENVELOPE TO THE STUDENT PRIOR TO THE APPLICATION DEADLINE OF FRIDAY, APRIL 22, 2016.

 

 

 

 

 

 

 

 

How long and in what capacity have you known this applicant?

 

 

 

 

 

 

 

Please describe the applicant’s strengths?

Please comment on the applicant’s area(s) of development. What efforts has the applicant made to improve?

How has the applicant contributed above and beyond her/his expected responsibilities?

Please use the following space to include any additional comments. (Optional)

Please rate the applicant on the following categories: Cannot Recommend Academic Performance Leadership Qualities Emotional Maturity Reliability Ability to interact with adults and peer Professionalism Resiliency (Ability to overcome barriers)  

Below Average

Average

Above Average

Excellent

  RECOMMENDATION  FORM  –  PLEASE  RETURN  THIS  WITH  YOUR  APPLICATION    

  To the Applicant Please fill in your name on the line below and give this information to the individual you have selected provide a recommendation for you.

Applicant’s Name To the recommending individual The student named above is applying to the UNM Health Sciences Center, Office for Diversity’s Medical College Admission Test + (MCAT+) Program. This program’s purpose is to prepare students to take the MCAT by providing test preparatory for its participants so they can become competitive applicants to medical school. This program will challenge student achievement by balancing a rigorous curriculum with academic, social, and developmental support. This program seeks to identify students who demonstrate the following characteristics: • • • • •

Financial need; Academic performance or promise; Interest in pursuing a health related career; Strength of character, evidence of leadership potential, and emotional maturity and stability; The potential to contribute to one’s community later in life.

Please provide your contact information below, in the case that the Office for Diversity staff has any pending questions or concern. Recommender Name: Phone Number: Email: Relationship to Applicant: To help in the selection of participants into the Medical College Admission Test + Program, we ask that you please answer all of the following questions. Please limit your answers to the allotted space provided. ALL COMPLETED RECOMMENDATION FORMS MUST BE SUBMITTED IN A SEALED ENVELOPE TO THE STUDENT PRIOR TO THE APPLICATION DEADLINE OF FRIDAY, APRIL 22, 2016.

 

 

 

 

 

 

 

 

How long and in what capacity have you known this applicant?

 

 

 

 

 

 

 

Please describe the applicant’s strengths?

Please comment on the applicant’s area(s) of development. What efforts has the applicant made to improve?

How has the applicant contributed above and beyond her/his expected responsibilities?

Please use the following space to include any additional comments. (Optional)

Please rate the applicant on the following categories: Cannot Recommend Academic Performance Leadership Qualities Emotional Maturity Reliability Ability to interact with adults and peer Professionalism Resiliency (Ability to overcome barriers)  

Below Average

Average

Above Average

Excellent